- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.07 / $11.07 / $11.07
| Facility | | $11.07 | $11.07 | $11.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.07 / $11.71 / $20.28
| Professional | | $11.07 | $11.71 | $20.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.88 / $53.64 / $60.56
| Facility | | $37.88 | $53.64 | $60.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $14.09 / $22.96
| Professional | | $11.98 | $14.09 | $22.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.93 / $10.93 / $12.04
| Professional | | $10.93 | $10.93 | $12.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.19 / $13.37 / $22.28
| Professional | | $10.19 | $13.37 | $22.28 |